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cardiology > clinical approach to a patient with heart disease > Flashcards

clinical approach to a patient with heart disease Flashcards

1
Q

what are symptoms that occur with heart disease

A
  • chest pain
  • palpitations
  • syncope
  • dyspnoea
  • fatigue
  • peripheral oedema
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2
Q

what cardiac diseases does central chest pain point towards

A
  • ischaemic heart disease
  • coronary artery spasm
  • pericarditis/ myocarditis
  • mitral valve prolapse
  • aortic aneurysm/dissection
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3
Q

what non cardiac diseases does central chest pain point towards

A
  • pulmonary embolism

- oesophageal disease

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4
Q

what pulmonary disease does lateral/peripheral chest pain point towards

A
  • infarction
  • pneumonia
  • pneumothorax
  • lung cancer
  • mesothelia
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5
Q

what chest pain does angina present with

A

retrosternal heavy or gripping sensation with radiation to the left arm or neck that is provoked on exertion and lessened with nitrates

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6
Q

what type of pain is aortic dissection

A

severe, tearing chest pain radiating to the back

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7
Q

what type of chest pain is pericarditis

A

sharp, central chest pain that is worse with movement or respiration but relived with sitting forward

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8
Q

what’s orthopnea

A

breathlessness on lying flat

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9
Q

what’s paroxysmal nocturnal dyspnoea

A

when a patient wakes up fighting for breath

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10
Q

what are palpitations

A

Heart palpitations are the sensation that your heart has skipped a beat or added an extra beat. It may also feel like your heart is racing, pounding, or fluttering. You may become overly aware of your heartbeat.

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11
Q

what are premature beats (ectopic beats)

A
  • Felt as a pause and then a forceful beat.

- The second beat is more forceful as the heart has had a longer diastolic period and hence is filled with more blood

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12
Q

what are paroxysmal tachycardias

A

sudden racing heartbeats

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13
Q

what is bradycardia

A

slow, regular heavy or forceful beats

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14
Q

what is syncope

A

the transient loss of consciousness due to inadequate central blood flow

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15
Q

what is a vasovagal attack

A

a simple faint

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16
Q

what is postural (orthostatic) hypotension

A

a drop in systolic BP by 20mmHg or more on standing from a sitting position

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17
Q

what is postprandial hypotension

A

a drop in systolic pressure of 20mmHg or more, or the systolic pressure drops from over 100mmHg to below 90mmHg within 2 hours of eating

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18
Q

what is micturition syncope

A

loss of consciousness while passing urine

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19
Q

what is carotid sinus syncope

A

occurs when there is an exaggerated vagal response to carotid sinus stimulation, provoked by wearing a tight collar, looking upwards or turning head

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20
Q

what is strokes-Adams attack

A
  • sudden loss in consciousness caused by intermittent high grade AV block, profound bradycardia or ventricular standstill.
  • the patient falls to the ground with no warning and is pale and deeply unconscious
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21
Q

why does peripheral oedema occur in heart failure

A

heart failure results in salt and water retention due to renal under perfusion and consequent activation of the RAAS system –> pitting oedema

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22
Q

cardio - general exam

A
  • clubbing - seen in congenital cyanotic heart disease and subacute infective endocarditis
  • splinter haemorrhages - frequently due to trauma and seen in infective endocarditis
  • cyanosis - occurs when the oxygen saturation is less than 85%
    ~ central cyanosis = right to left heart shunt
    ~ peripheral cyanosis = congestive heart failure, circulatory shock, abnormalities in the peripheral circulation
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23
Q

what should the normal pulse rate be

A

60-80 bpm when lying down

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24
Q

what are premature beats

A

occur as occasional or repeated irregularities superimposed on a regular pulse rhythm.

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25
Q

what is atrial fibrillation

A
  • produces and irregularly irregular pulse

- the irregular pattern persists when the pulse quickens in response to exercise

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26
Q

what is a collapsing or water hammer pulse

A

large volume pulse characterised by a short duration with a brisk rise and fall

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27
Q

what is a small-volume pulse

A

seen in cardiac failure, shock and obstructive valvular disease

28
Q

what is a plateau pulse

A

a small in volume and slow in rising to a peak: due to aortic stenosis

29
Q

what is an alternating pulse (pulses alternans)

A

regular alternative beats that are weak and strong

  • feature of severe myocardial failure and is due to a prolonged recovery time of damaged myocardium
30
Q

what is a bigeminal pulse (pulses bigeminus)

A

caused by a premature ectopic beat following every sinus beat

  • the rhythm is not regular as every weak pulse is premature
31
Q

what is a dicrotic pulse

A

results from an accentuated dicrotic wave

  • occurs in sepsis and hypovalemic shock
32
Q

what information does measuring the JVP give you

A

observation of the column of blood in the internal jugular system is a good measure of right atrial pressure as there are no valves between the internal jugular vein and the right atrium

33
Q

what does an elevated JVP symbolise

A
  • heart failure
  • constrictive pericarditis
  • renal disease with salt and water retention
  • congestive cardiac failure
34
Q

what are the 3 waves and 2 troughs of the JVP pressure wave

A
  • the peaks are a, c, v

- the troughs are x and y

35
Q

where is the cardiac apex located

A

5th intercostal space of the midclavicular line

36
Q

what causes the apex to move downwards and laterally

A

left ventricular dilatation

37
Q

what is a tapping apex

A

a palpable first sound and occurs in mitral stenosis

38
Q

what is a vigorous apex

A

may be present in diseases with a volume overload

39
Q

what is a heaving apex

A

may occur with left ventricular hypertrophy - aortic stenosis, systemic hypertension and hypertrophy cardiomyopathy

40
Q

what is a double pulsation of the apex beat

A

may occur in hypertrophic cardiomyopathy

41
Q

what is a sustained left parasternal heave

A

occurs with right ventricular hypertrophy or left atrial enlargement

42
Q

what is a palpable thrill

A

may be felt overlying an abnormal cardiac valve

43
Q

what is the first heart sound (S1)

A

due to mitral and tricuspid valve closure

  • loud = skinny people, hyper dynamic circulation, tachycardias
  • soft = obesity, emphysema, pericardial effusion, mitral or tricuspid regurgitation
44
Q

what is the second heart sound (S2)

A

Due to aortic and pulmonary valve closure

45
Q

what causes a third heart sound

A

“volume overload” - rapid ventricular filling and is present in heart failure

46
Q

what causes a fourth heart sound

A

pressure overload = occurs in late diastole and is associated with atrial contraction

  • caused by aortic stenosis, severe systemic hypertension and left ventricular outflow obstruction
47
Q

what causes heart murmurs

A

due to turbulent blood flow and occur in hyperdynamic states or abnormal valves

48
Q

where are the heart auscultation areas on the precordium

A
  • aortic area = second intercostal space at the right sternal edge
  • pulmonary area = second intercostal area at the left sternal edge
  • mitral area = fifth IC at the midclavicular line
  • tricuspid area = third to fifth ICS at the left sternal edge
49
Q

what is the normal cardiothoracic ratio

A

less than 50%

  • a transverse cardiac diameter more than 15.5 is abnormal
50
Q

what are some types of heart enlargement seen on a chest x ray

A
  • left atrial dilatation
  • left ventricular enlargement
  • right atrial enlargement
  • right ventricular enlargement
  • ascending aortic dilation or enlargement
  • dissection of the ascending aorta
  • enlargement of the pulmonary artery
51
Q

why does calcification of the CV system occur

A

Due to tissue degeneration

52
Q

what is first degree AV block

A
  • consistent prolongation of the PR interval (defined as >0.20 seconds) due to delayed conduction via the atrioventricular node.
  • every P wave followed by a QRS wave
53
Q

what are ECG findings on first degree AV block

A
  • regular rhythm

- p waves always present followed by a QRS

54
Q

what are clinical features of first degree AV block

A

usually asymptomatic

55
Q

what is second degree AV block type 1

A
  • also known as Morbitz type 1 AV block
  • progressive prolongation of PR interval until the atrial impulse is not conducted and the QRS complex is dropped
  • AV nodal conduction resumes with the next beat and the sequence of progressive PR interval prolongation and the eventual dropping of a QRS complex repeats itself
56
Q

what is the aetiology of second degree AV block type 1

A
  • Increased vagal tone – often seen in athletes (non-pathological)
  • Drugs – beta-blockers, calcium channel blockers, digoxin, amiodarone
  • Inferior myocardial infarction
  • Myocarditis
  • Cardiac surgery (mitral valve repair, Tetralogy of Fallot repair)
57
Q

what are ECG findings of second degree AV block type 1

A
  • irregular rhythm
  • every p wave is present bit not all are followed by a QRS complex
  • PR interval progressivly lenthens before a QRS complex is dropped
58
Q

what are clinical features of second degree AV block type 1

A

usually asymptomatic but can develop some bradycardia and present with symptoms such as presyncope and syncope

59
Q

what is the management of second degree AV block with type 1

A
  • AV blocking drugs should be stopped
  • Second-degree AV block (type 1) is usually benign and rarely causing haemodynamic compromise2
  • Usually, no intervention is required if the patient is asymptomatic
  • If the patient is symptomatic a pacemaker may be considered
60
Q

what is second degree AV block type 2

A
  • also known as morbitz type 2 AV block
  • consistent PR interval duration with intermittently dropped QRS complexes due to a failure of conduction.
  • The intermittent dropping of the QRS complexes typically follows a repeating cycle of every 3rd (3:1 block) or 4th (4:1 block) P wave.
61
Q

what is aetiology of second degree AV block type 2

A
  • always pathological with the block at the bundle of his or the bundle branches
  • MI
  • Idiopathic fibrosis of the conducting system
  • Cardiac surgery
62
Q

what are ECG findings of the second degree AV block type 2

A
  • irregular rhythm
  • p wave present but there are more p waves than QRS complexes
  • consistent normal PR interval duration with intermittently dropped QRS complexes
63
Q

what are clinical features of second degree AV block type 2

A
  • asymptomatic
  • palpitations
  • pre-syncope
  • syncope
  • regularly irregular pulse
64
Q

what is third degree (complete) AV block

A
  • when there is no electrical communication between atria and ventricles die to a complete failure of conduction
  • p waves and QRS complexes that have no association with eachother due to atria and ventricles working independently
  • narrow complex escape rhythm origionate above the birfurcation of the bundle of His
65
Q

what causes third degree AV block

A
  • congenital
  • idiopathic fibrosis
  • ischaemic heart disease
  • non ischaemic heart disease
  • Iatrogenic
  • drug related
  • infections
  • autoimmune conditions
66
Q

what are ECG findings of third degree AV block

A
  • variable rhythm
  • p wave present but not associated with the QRS
  • PR interval abscent
67
Q

what are clinical features of the third degree AV block

A
  • palipitations
  • pre syncope
  • confusion
  • SOB
  • chest pain
  • sudden cardiac death
  • irregular pulse
  • profound bradycardia

cardiology (13 decks)

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